Is the current shortage in obstetric services in rural areas contributing to adverse perinatal outcomes? Despite the importance of this question, few studies have compared pregnancy outcomes for women residing in rural areas with obstetric care provider shortages with outcomes for women residing elsewhere and none have adequately adjusted for demographic and other differences. The objective of this proposal is to test the hypothesis that women residing in rural areas with obstetric care provider shortages receive less prenatal care and have more adverse pregnancy outcomes than other women. With 28% of its childbearing population residing in rural areas, Tennessee is well suited as the focus of a study on obstetric care provider shortage. A recent statewide review of primary health care services has objectively classified every county as to the availability of obstetric care providers based on a formal criterion of caseload and/or population per delivering physician. Other resources include: a linked vital records and maternal Medicaid enrollment data base and Perinatal Risk Factor Surveillance Program data base. This latter data base contains nurse abstracted information from the hospital medical records of all Tennessee infants born with very low birth weight (<1500 grams) and all Tennessee infants who die in the first 28 days of life (the cases) and a random sample of non-case infants (the controls). Data from the linked vital records - maternal Medicaid enrollment file will be used to conduct a population-based cohort study of the impact of obstetric provider shortage and maternal residence on prenatal care (as measured by first trimester care and the Kessner Index) and pregnancy outcome (as measured by the occurrence of very low birth weight, moderately low birth weight, neonatal mortality and perinatal mortality). Multivariate techniques will be used to adjust for potentially confounding demographic variables including maternal Medicaid status. Data from the Perinatal Risk Factor Surveillance Program data base will be used to conduct a nested case control study which will explore the influence of obstetric care provider shortage and maternal residence on the recognized risk factors associated with adverse perinatal outcome. These risk factors include: maternal life style (e.g., cigarette smoking), maternal medical problems (e.g., anemia), complications of labor and delivery, transport of mother and infant, and newborn complications.